Approach Considerations
Supportive care and observation for signs of end-organ damage (eg, central nervous system [CNS], heart, lung, liver) are the mainstays of therapy. No specific antidotes are available for organochlorine poisoning. Decontamination may be indicated to prevent continued absorption, as well as exposure of health care personnel. For dermal decontamination, remove clothing and wash skin with soap and water. This is best performed in the field.
Observe patients with an apparent nonsignificant and nontoxic exposure in the emergency department (ED) for 6-8 hours. If any signs or symptoms of toxicity develop during that time, admit the patient to the hospital. Intensive care unit admission is indicated for patients with significant exposure or with signs and symptoms of intoxication.
Prehospital Care
Attend to the ABCs (airway, breathing, circulation). Protect the airway at all times.
Remove the patient from source of exposure and prevent contamination of others. Consider skin decontamination by washing with soap and water and removing clothing (place in plastic bags) as early as possible. Skin decontamination is performed best in the field.
Do not induce emesis, because the patient may have a sudden change in mental status and could aspirate gastric contents. Avoid strong external stimuli to the patient, which may precipitate convulsions. Initiate cooling measures if the patient is hyperthermic.
Do not forget that other persons still may be at risk of intoxication. Medically evaluate all of these persons as soon as possible. With massive exposure or multiple victims, contact a hazardous materials (HAZMAT) team for assistance.
Emergency Department Treatment
Repeated assessments of the patient’s airway, breathing, and circulation (ABCs) and vital signs are of extreme importance in cases of acute poisoning. In particular, airway protection must be assured. Consider early rapid-sequence intubation to facilitate aggressive benzodiazepine use.
Seizures may begin without any prodromal signs or symptoms. If the patient is paralyzed after intubation, electroencephalographic monitoring is warranted. Termination of seizure activity should be attempted using traditional treatment algorithms, starting with benzodiazepines and progressing if necessary to phenytoin or fosphenytoin, propofol, and barbiturates. Rhabdomyolysis should be considered in patients with prolonged convulsions or those who have acute renal failure with or without hyperkalemia.
Continuous cardiac monitoring is indicated. Use epinephrine and sympathomimetic amines with caution because dysrhythmias can be induced, as a result of increased myocardial sensitization to catecholamines. Use of beta-blockers is reported to control ventricular dysrhythmias because of sensitized myocardium. If the patient is hypotensive and unresponsive to fluids, intravenous administration of a pure alpha-adrenergic agonist agent (eg, phenylephrine) is the therapy of choice.
In cases of ingestion, do not induce emesis. Insertion of a nasogastric tube for stomach evacuation is controversial; it may induce vomiting with subsequent aspiration. Carefully perform orogastric lavage with suction, especially for recent liquid ingestion. Always secure the airway well before executing lavage. If nasogastric suction is used, a small-bore tube should be used.
Regardless of the route of exposure, consider multiple-dose activated charcoal (MDAC) because it may enhance fecal elimination by interrupting the biliary-enterohepatic and enteroenteric recirculation of the toxin. MDAC should be used with caution because patients are at increased risk for seizures [28] and consequent aspiration. Aqueous-based activated charcoal should be used, as sorbitol-based activated charcoal may induce vomiting.
Cholestyramine may be used to bind these highly lipophilic agents. Cholestyramine reduces reabsorption and retains bound agent in the GI tract for fecal elimination. [29] In patients who have ingested chlordecone, multiple repeated doses of cholestyramine can be administered to interrupt enteroenteric and enterohepatic recirculation. [30]
Sucrose polyester (Olestra) has also been shown to increase excretion of fat-soluble organic chlorine chemicals. [31] Whole-bowel irrigation may be indicated, but it is not without risk and so should be performed only at the discretion of a medical toxicologist or a poison control center. Induced diuresis, hemodialysis, and hemoperfusion have not been shown to be effective enhanced elimination techniques.
If liver abnormality or necrosis is suspected (eg, because of elevated serum levels of liver enzymes), administration of N-acetylcysteine (NAC) may in theory prevent irreversible hepatic injury. Generally, the only significant adverse event associated with oral use of NAC is pulmonary aspiration; therefore, ensure proper protection of the airway.
In contrast to organophosphate poisoning, atropine and oximes are not established antidotes for organochlorine toxicity. [32] The use of steroids or prophylactic antibiotics for aspiration is controversial and cannot be recommended because of a lack of evidence for their efficacy. External cooling may be used for hyperthermia.
Arrange follow-up care before discharge so that the patient may be monitored for possible long-term sequelae. Arrange for patient education on proper storage and use of pesticides. Survey for ongoing exposure in the home and work environment is important.
Obtain a psychiatric evaluation, if warranted, before discharge. Explore the possibility of child, elder, or vulnerable adult abuse or neglect.
Consultations
In all cases, consult with the regional poison control center for information regarding the speciof fic ingestion. If possible, consult with a medical toxicologist (certified through the American Board of Medical Toxicology or the American Board of Emergency Medicine). In cases of occupational exposure, alert public health authorities to assist in prevention of further exposures in a potentially unsafe work environment.
Exposure may be caused by a work-related incident. Legally, the physician may be required to file a report to the state or local health department. Even if not legally required, reporting the exposure to prevent further cases from occurring may be wise. Organochlorines (with the exception of lindane) are banned by the US Environmental Protection Agency, so any use of these compounds is illegal.
